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Restricting PHI Disclosures for Patient Self-Pay Encounters or Services

If a patient wants to self-pay 100% in full for an item or service and asks that no bill be submitted to his/her insurance, immediately refer the patient to a Patient Financial Counselor (PFC). Email - PFC-counselors@med.umich.edu; telephone - 734-232-2621 (local) 877-326-9155 (toll-free)

Forms

UMHS:

• UMHS Protected Health Information Restriction (Self-pay) Request
• UMHS Release Restriction Revocation
• Home Care Services Protected Health Information Restriction (Self-Pay) Request
• Home Care Services Release Restriction Revocation

Training/Workflows:

• Ambulatory Care Training Presentation for Restricted Disclosure/PHI Release Restriction Requests (powerpoint)
• Workflows for managing Restricted Disclosure of PHI, Patient Self-Pay Requests

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